Bringing it back to health care

In a break from my feminist rantings, I found this post from the Health Affairs blog (in an effort to to read other health care blogs). Frank Opelka, a professor of surgery and vice chancellor for clinical affairs at the Louisiana State University Health Science Center, discusses the problems with the way the sustainable growth rate is currently calculated, a better way that it could be calculated and the problems that would be encountered (and overcome!) in implementing his suggested system.

I'm not going to go into the problems with the SGR (see my previous post on Leavitt's blog post of the subject), but I think Opelka's endorsement of a MedPAC suggestion has merit. MedPAC suggested, as part of a Deficit Reduction Act mandate, that the government create "unique Service Category Growth Rate (SCGR) targets as well as payments based on participation in a system of care," noting, "In each proposal, the goal is to avoid the blunt, lofty economic drivers and provide physician incentives to moderate growth in volume and intensity within a geographic setting, specialty base, or system of care," i.e. regional, rather than a national, targets.

In general, when it comes to measures based on economic indicators (like eligibility guidelines for public programs), I think that regional is always better. It does not cost the same to practice medicine in middle-of-nowhere Nebraska as it does in New York City. Regional just makes more sense.

He adds a bit about incorporating quality measures into the SCGR:

These quality tools could serve as a valuable resource for regions and systems of care to promote evidence-based, efficient care. Physicians, medical groups, and hospitals will need to use the current measurements available for comparison against their peers and national benchmarks. Through payment incentives and a clinically focused approach, regional efforts and systems of care will have a greater opportunity to reach individual providers.

Concluding

The best model for modifying the SGR likely includes both regional targets and assessment of spending by specialty. The true answer lies in changing the reward system so that physicians are rewarded for collaborating and making decisions in the best interest of the patient and the overall health care system. The payment system can no longer pay blindly on volume, but must instead financially encourage providers to remove waste and promote efficient, high-quality care. The SGR is too far removed to change behavior at the individual provider level. Regional and service category proposals will bring the requirements closer to the individual, but it is important that unintended consequences be modeled in advance and offset by mandatory quality targets.

I think Congress is supposed to tackle this sometime this session, although I seriously doubt that they will (seems a bit too complicated for lawmakers to handle). But maybe next session, if Democrats can manage to win control of both houses and the presidency. Even if they don't, someone needs to tackle the SGR revision, and soon.

Leavitt on the SGR -- A Simple Solution for a Complex Problem

I'll admit it, I'm embarrassed. It's been over a month since my last post, which, although for perfectly legitimate reasons, is still unacceptable. Since it's Sunday night and I'm not at work and have no inspiration, I've turned to Leavitt's blog for a topic.

Leavitt's last post, dated Dec. 3 (he is a much better blogger than I), discusses the SGR, or sustainable growth rate, update. This rate determines how much physicians are paid for specific procedures. Because of the way that it's formulated, SGR updates actually would have been negative updates in the costs of procedures over the last couple of years. Obviously, giving physicians less and less money for the same procedure has not gone over too well for an industry with a very well-organized lobby. So physicians have successfully lobbied over the last couple of years to overturn the negative update and get a small increase. Which in turn, increases the negative rate increase for the next year.

It's a pretty sick cycle, and this year physicians are stuck lobbying against a 10% cut to their payments. That's huge. According to Leavitt,

This is a lousy system and it hasn’t reduced Medicare costs. The total expenditures just keep going up. Why? When rates per procedure don’t go up, doctors have simply done more procedures.

I think this is slightly simplistic reasoning for why the rates have increased. Nevertheless, Leavitt makes an interesting suggestion for fixing this obviously screwed up system:

Long term, the solution to this problem is to change the way we pay doctors. At least some portion of their payment should be based on how successful they are in keeping people healthy, rather that just the volume of procedures they perform [pay for performance].... [W]e cannot make progress unless doctors adopt a system of electronic medical records. Such a system depends on being able to gather quality data electronically.

What struck me as most interesting was his shift from a pay-for-performance system to EHRs. I am a full supporter of the EHR, but I'm not really sure how its adoption will lead to us correct the $200 billion deficit Leavitt earlier in the post says that we have from not reducing reimbursements to physicians. His prescription:

It is the position of the Administration that any new bill overriding the SGR law should require physicians to implement health information technology that meets department standards for interoperability in order to be eligible for higher payments from Medicare.

The connection between EHRs and pay-for-performance systems is a little tenuous. It's one thing for HHS to tell doctors to stop charging the government for their screw ups -- it's a complete other to mandate that doctors adopt costly technology or they won't get a raise. It would be completely awful to implement such a mandate without some financial assistance, especially for Medicare beneficiaries in rural areas where it's already difficult to find doctors who accept Medicare.

I guess I was expecting Leavitt to argue for a more, um, comprehensive reform. EHRs are great, and if you need to tie them to the SGR in order to ensure that they are implemented, go for it. But don't act like the fix to the growing problem of physicians payments can be encapsulated in better technology.

Let's talk Mayo Clinic

and Hillary, for that matter.

But focusing on the Mayo Clinic for a sec ... The clinic on Friday released 19 recommendations for health care reform. One of their major proposals is to make health insurance more portable. I mentioned this topic in my last post. I simply cannot stress enough how much I support portable health insurance. It doesn't make any sense to have it tied to employers anymore. I mean, hello, people of my generation have extreme ADD when it comes to holding a job. How are we ever supposed to establish a connection with a doctor, which will help us receive better, more coordinated care, if we keep having to change insurance providers every year and a half? New York Times says that one and four change jobs every year ... and I think they might be referring to me, haha.

What really surprised me about the coverage on this was the employer response. According to the Times,

Executives of several large employers who took part in the Mayo discussions agreed that rising medical costs and the aging of the baby boomer generation were pushing the current system toward a crisis. But they said they were not ready to abandon their current health plans for employees.

“We do not believe in relinquishing the employer-sponsored health care system,” said Anthony C. Wisniewski, a Mayo panelist who is executive director of health care policy at the United States Chamber of Commerce.

That's basically all the article says about it, which is kind of annoying because I want to know WHY they don't want to give up health insurance. It would make them totally more profitable. God knows those car makers are itching to drop insurance coverage ... why not businesses in the Chamber of Commerce? Perhaps because a good insurance plan makes a job offer more attractive? Hard to say without a better background in business.

You can read the rest of the recommendations here. Overall, I felt like the recommendations were very thought out .. radical but not so radical it couldn't be done. I'm very hopeful that Hillary will implement some of their recommendations into her reform. The whole quality-cost debate I think is pretty standard, but portability is something I would really like to see implemented.

Now on to discussing my girl Hill's proposal. Since I didn't cover it at work (as I did the Mayo Clinic) this is news to me too. Looking a press release from today on her website, the final prong of her three prong plan includes none other than --- PORTABILITY. (Full disclosure: I love Hillary. I volunteer for her campaign. Which truly demonstrates my love because I hate making cold calls ... but for her, I do it.). She even throws in tax credits. Listen to her: "If you like the plan you have, you can keep it." It's genius. She has some other good things outlined in the press release, so I recommend reading it.

From a different press release (the mainstream media will have more detailed coverage tomorrow ... if I have time I'll post some the main pieces so I am not completely one-sided.):

If you’re one of the tens of million Americans without coverage or if you don’t like the coverage you have, you will have a choice of plans to pick from and that coverage will be affordable. Of course, if you like the plan you have, you can keep it.

• Affordable: Unlike the current health system where insurance premiums send people into bankruptcy, the plan provides tax credits for working families to help them cover their costs. The tax credits will ensure that working families never have to pay more than a limited percentage of their income for health care.
• Available: No discrimination. The insurance companies can’t deny you coverage if you have a pre-existing condition.
• Reliable: It’s portable. If you change or lose your job, you keep your health care.

...If you have a plan you like, you keep it. If you want to change plans or aren’t currently covered, you can choose from dozens of the same plans available to members of Congress, or you can opt into a public plan option like Medicare. And working families will get tax credits to help pay their premiums.

Reading this shit practically makes me giddy. Also, hopefully you caught last week's Newsweek, which had extensive coverage about Hillary and "what kind of decision maker she'd be." It has some good insight into the lessons she's learned from the failed health care reform attempt of 1993/4. Here's a different web exclusive article on health care and Hillary.

For once I'm not going to write about S-Chip

There was an interesting opinion piece by Michael Cannon, director of health policy studies at the Cato Institute, in today's USA Today. Cannon argues that so many of the uninsured have access to insurance ("As many as 20% of the "uninsured" are eligible for government health programs, so in effect they are insured. On top of that, economists Kate Bundorf of Stanford University and Mark Pauly estimate that as many as 75% of the uninsured can afford to buy insurance," he writes), increasing access to health care isn't really the problem we should be focusing on ... cost is.

He writes:

Simply expanding coverage would have little effect on the quality of care, health disparities, or how long we live, nor would it stop free-riders from shifting costs to others. In fact, expanding coverage through government regulation or tax-and-transfer programs would make our problem worse.

He makes a point about the rising cost of premiums, that they aren't

some inevitable result of market forces, but of government programs and tax preferences for employer-controlled insurance. By rewarding employer-controlled coverage — and penalizing plans that stay with you from job to job — the government strips people of their health insurance when they need it most.

He then goes on to support Bush's tax breaks. I'm not completely sure how I feel about that (I know very little about taxes, just that I seem to pay a large proportion of my very small paycheck), but I think Cannon makes a good point that plans that travel should not be penalized, especially since I do think they will be the new way of purchasing health care in the future. Regional purchasing pools are the wave of the future, I'm telling you.

Back to Cannnon ... he ends by saying

If we want to increase access to health care, our first priority must be to contain costs. Nothing would help more than 200 million cost-conscious consumers.

Letting Americans own their health care dollars is the right thing to do. And as it happens, it would also cover a lot of the uninsured.

Cannon makes some very valid points. Cost containment must happen. We as a nation cannot continue to spend as much on health care as we do. And obviously this ties into a couple other areas, such as increasing preventive care and overall health. High insurance and hospital fees are not completely to blame here ... so is obesity and not exercising and smoking and not getting regular check-ups. A change in tax policy is not going to lower costs on its own. We need to have a different view toward health altogether.